Stelmach-Mardas et al Health and Quality of Life Outcomes (2016) 14:111 DOI 10.1186/s12955-016-0516-5 RESEARCH Open Access Quality of life, depression and dietary intake in Obstructive Sleep Apnea patients Marta Stelmach-Mardas1,2* , Marcin Mardas3, Khalid Iqbal1, Robert J Tower4, Heiner Boeing1 and Tomasz Piorunek5 Abstract Background: The aim of this study was to analyze the association between depression, quality of life and dietary intake in newly diagnosed Obstructive Sleep Apnea (OSA) patients Methods: From 153 eligible patients suffering from sleep disturbances, 64 met inclusion and exclusion criteria The polysomnography was used for OSA diagnosis The quality of life (QOL) was assessed by WHOQOL-BREF questionnaire, self-reported chronotype by morningness-eveningness questionnaire and level of depression by Beck’s Depression Inventory Blood pressure and parameters of glucose and lipid metabolism were assessed by routine methods The dietary intake was evaluated by 24-hr dietary recalls Results: Significantly negative associations were found between depression inventory and QOL Better QOL for physical health and social relationships was observed in the “definitely morning” chronotype The “morning type” of patients was positively related to the intake of fat, monounsaturated fatty acids and vitamin B12 Correlations between QOL and diastolic blood pressure, HDL-cholesterol, TG, fasting glucose, as well as protein and vitamin B6 intake were found Conclusions: In conclusion, both chornotype and depression influence QOL in OSA patients where morning type is associated with better physical health and social relationships and increase in depression index deteriorate physical health, psychological and social relationship QOL domains QOL as well as depression and chornotype are also influenced by selected cardio-metabolic factors and dietary intake Keywords: Sleep Apnea, Chronotype, Diet, Biomarkers Background Obstructive Sleep Apnea (OSA) is characterized by repetitive partial or complete closure of the upper airway during sleep that results in hypoxemia and hypercapnia, frequently associated with arousals [1] OSA is potentially related to daytime sleepiness and different comorbidities e.g hypertension, insulin-resistance and obesity [2–4] Moreover, the diagnoses of depression is also emerging in OSA patients since the early 2000s However, the relationship between such symptoms and objectively-rated features of OSA is still poorly understood [5, 6] * Correspondence: stelmach@dife.de Department of Epidemiology, German Institute of Human Nutrition Potsdam-Rehbruecke, Arthurt-Scheunert Alee Str 114-116, 14558 Nuthetal, Germany Department of Pediatric Gastroenterology and Metabolic Diseases, Poznan University of Medical Sciences, Szpitalna Str 27/33, 60-572 Poznan, Poland Full list of author information is available at the end of the article In addition, OSA negatively affects quality of life (QOL) and increases the risk of other comorbidities [7] Since health related QOL in patients is recognized as an important part of diseases processes in terms of disease diagnosis and treatment success, an assessment of QOL in OSA patients is of considerable interest to improve treatment outcomes [8] Breathing-related sleep disordered are usually associated with a poorer QOL - especially in social, emotional and physical domains [9] Nevertheless, there are still some inconsistencies in regards to the relationship between sleepness, mood and QOL It has been even reported in the cohort study that individuals with mild OSA not have worse sleepiness, mood or quality of life in comparison to those without OSA [10] QOL may also be affected by individuals’ chronotype, i.e morning or evening type, and may be important to consider for management of OSA © 2016 The Author(s) Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated Stelmach-Mardas et al Health and Quality of Life Outcomes (2016) 14:111 Furthermore, while the unique importance of lifestyle factors in OSA patients has already been emphasized [11, 12], there is still insufficient evidence regarding dietary intake and its association with QOL and depression in this group of patients, which may be important to include in successful OSA treatment regimes For successful treatment of OSA, it is critical to generate evidence regarding whether chronotype, quality of life, depression and nutrient intake are of importance in this population This study was planned to address these questions with the specific aims to evaluate the association of chronotype and depression with quality of life, as well as to assess the correlation of cardio-metabolic risk factors and nutrients intake with QOL domains, depression and chronotype Methods Study design and patient population This was a cross-sectional study We recruited patients which were admitted to the Department of Pulmonology, Allergology and Respiratory Oncology at the Poznan University of Medical Sciences in Poland for diagnostics of sleep disturbances (suspected OSA) Inclusion criteria were as follows: age above 18, signs of OSA (snoring, apnea during sleep, morning tiredness, increased daytime sleepiness etc.), willingness to participate in the study, being on habitual diet during the period of examination Exclusion criteria included: pregnancy or lactation, cancer (excluding curatively treated with no evidence of diseases for years), severe liver and kidney diseases, diagnosed cardiovascular diseases (myocardial infarct, stroke, angina pectoris) An active drug or alcohol abuse, legal incompetence and limited legal competence were additional exclusion criteria One hundred fifty three patients were screened for OSA Sixty four individuals met above criteria and were included in the study Written informed consent was obtained from all the subjects who agreed to participate in the study Medical history, comorbidities, concomitant medications were recorded in electronic database Experimental protocol was approved by Bioethical Committee (400/15) at Poznan University of Medical Sciences Anthropometry appraisals, assessment of circadian rhythms and depression inventory The anthropometrical parameters included body weight and height (Seca digital scale 763, US) Height was measured using a stadiometer (with an accuracy of ±0.5 cm), and weight using a digital scale (with an accuracy of ±0.1 kg), while wearing light clothing and without shoes Body Mass Index (BMI) was calculated to determine the degree of obesity in the study groups [13] The polysomnography (PSG) was used as the standard method for OSA diagnosis (Embla 4500, Inc, by the Beth Page of Israel Deaconess Medical) The American Academy of Sleep Medicine (AASM) recommendations [14] regarding filters, sample signal rates and configurations were followed Flow tracing was provided by a nasal cannula and thermistor, thoracoabdominal motion by piezoelectric bands Oxygen saturation was measured with a pulse oximeter The apnea hypopnea index (AHI) was defined as a total number of apnea and hypopnea events divided by the total sleep time Apnea was noted at the cessation of airflow for at least 10 s and whereas hypopnea was reported as ≥80 % reduction in airflow for at least 10 s (taking into account an amplitude) [15] According to the AHI, OSA was classified into mild (5.0– 14.9), moderate (15.0–29.9), and severe (≥30.0 events per hour) [16] Oxygen desaturation Index (ODI) was defined as a number of significant episodes of desaturation per hour of sleep (Δ > %) [15] The electroencephalogram (EEG) was used as the primary variable to document wakefulness, arousals and sleep stages during the sleep study PSG was analyzed by an experienced pulmonologist (TP) Morningness - eveningness questionnaire All patients completed the morningness - eveningness questionnaire to assess morningness-eveningness in human circadian rhythms The questionnaire consists of 19 questions, each with a number of points Total scores can range from 16 to 86 Scores of 41 and below indicated “evening types”, scores of 59 and above - “morning types” and scores between 42 and 58 indicated “intermediate types” [17] The Beck’s depression inventory To assess the self-reported level of depression, we used Beck’s depression inventory It consisted of 21 questions, each with a number of points with a possible total score 63 Total scores of 1–10 was considered as normal, 11–16 as moderate mood disturbances, 17–20 as borderline clinical depression, 21–30 as moderate depression, and 31–40 indicate severe depression [18] Assessment of quality of life WHO Quality of Life-BREF (WHOQOL-BREF) was used as a shorter version of the original instrument (WHOQOL-100) to assess the quality of life of OSA patients It comprises 26 items which measure the following broad domains including selected facts: physical health, (activities of daily living, dependence on medicinal substances and medical aids, energy and fatigue, mobility, pain and discomfort, sleep and rest, work capacity) psychological health (body image and appearance, negative feelings, positive feelings, self-esteem spirituality/religion/personal beliefs, thinking, learning, memory and concentration), social relationships (personal Stelmach-Mardas et al Health and Quality of Life Outcomes (2016) 14:111 relationships, social support, sexual activity), and environment (financial resources, freedom, physical safety and security, health and social care: accessibility and quality, home environment, opportunities for acquiring new information and skills, participation in and opportunities for recreation/leisure activities, physical environment, transport) There were also two items that were examined separately: question asked about patient’s overall perception of quality of life and question asked about patient’s overall perception of their health The four domain scores denoted patient’s perception of quality of life in each particular domain Domain scores were scaled in a positive direction (i.e higher scores denote higher quality of life) The mean score of items within each domain were used to calculate the domain score [19] Assessment of selected cardio-metabolic biomarkers and blood pressure All blood samples were collected after 12 h of overnight fasting at the day of examination The lipid profile containing serum total cholesterol (TC), high density lipoprotein-cholesterol (HDL-C) and triglycerides (TG) was determined by enzymatic colorimetric methods (Roche Diagnostics Corp., Indianapolis IN) [20–24] Low density lipoprotein-cholesterol (LDL-C) was calculated according to Friedewald et al [25] Disturbance in lipid profile was assessed according to the National Health and Nutrition Examination Survey [26] The level of fasting blood glucose and glucose tolerance test were determined by the routine enzymatic method The glucose metabolism was interpreted according to the American Diabetes Federation [27] Blood pressure (BP) was measured during the study visit with a digital electronic tensiometer (Omron Corp., Kyoto, Japan) after a resting period of 10 The mean of three consecutive measurements were taken in the non-dominant arm with 3-min intervals between readings Regular or large adult cuffs were used, depending on arm circumference of the examined patient BP measurements were performed in accordance with the guidelines of the European Society of Hypertension [28] Nutritional assessment The dietary intake was evaluated by 24 h dietary recall (Dietetyk, National Institute of Food and Nutrition, Warsaw, Poland) The local tables of food portion sizes and the weights of foods displayed in photos were used to estimate the amounts of food consumed Several nutritional factors including total energy, carbohydrates, proteins, fats, fatty acids (saturated fatty acids-SFA, monounsaturated fatty acids-MUFA, polyunsaturated Page of fatty acids-PUFA), selected vitamins (vitamin B1, B2, B6, B12, D and folate) were surveyed Statistical approach All statistical analyses were conducted with SAS Enterprise version 6.1 (SAS Institute Inc USA) Single imputation was used to impute missing values using chained equations [29] by invoking Proc MI statement in SAS Categorical variables were described using percentages and frequencies while continuous variables were described using mean and standard deviations Statistical difference in background characteristics of study individuals were assessed using t-tests for continuous and Fischer’s exact test and Chi-square tests for categorical variables Analysis of covariance (ANCOVA) was used to assess association of chronotype with quality of life domains and depression inventory A similar method was also used to assess association between the quality of life domains and depression ANCOVA assumptions of same slope across the groups were assessed by including the grouping variable along with covariates and the interaction term Results did not indicate that there were interactions among covariates and the groups under study Therefore, models without interaction were run for analysis Age and sexadjusted correlations were used to assess an association between quality of life domain and depression with objectively measured AHI, cardio-metabolic risk factors and nutrient intake All analyses were adjusted for age and sex Results Baseline characteristics are presented in Table Comparison between sexes showed that mean BMIs exceeded 30 kg/m2 in both groups However, mean age was significantly higher in males, as well as the percentage of divorced males was higher in comparison to other marital statuses and females There were no significant differences between alcohol drinks consumption, percentage of smokers, educational level, financial status and architecture of sleep between males and females The mean AHI values exceeded 25 events per hour Association of self-reported chronotype with quality of life and depression in study patients is shown in Table Patients with morning type had significantly better physical health as compared to patient with intermediate or evening types Other QOL domains including psychological, social relationship and environment however did not differed significantly between chronotype groups, there were significant liner trend for social health and near to significant trend for psychological domain (Fig 1) Similarly there was a Stelmach-Mardas et al Health and Quality of Life Outcomes (2016) 14:111 Table Basic characteristics of studied patients with Obstructive Sleep Apnea (n = 64) Analyzed variables Males Females Number 59.4 (38) 40.6(26) Age (year) 60.3 ± 9.1 53 ± 12.1 p-value 0.01 Alcohol drinks consumption (g/day) 65.5 ± 46.4 63.5 ± 37.6 0.85 BMI (kg/m2) 31.3 ± 6.7 32.6 ± 5.5 0.38 Smokers (%) 66.36 (4) 63.64 (7) 0.99e Primary school 15.4 (4) 15.8 (6) 0.28 Highschool 65.4 (17) 47.4 (18) University degree 19.2 (5) 36.8 ( 14) Single 7.7 (2) 15.8 (6) Married 69.2 (18) 76.3 (29) Education (%) Marital Status (%) Divorced 23.1 (6) 2.6 (1) Widowed (0) 5.3 (2) 11.5 (3) 15.8 (6) 0.04e Financial Status (%) Poor 0.42e Good 84.6 (22) 71.1 (27) Very good 3.9 (1) 13.2 (5) AHI (events per hours)a 25.1 ± 25.7 25.4 ± 19.7 0.95 ODI (events per hours)b 26 ± 25.1 24.8 ± 20.2 0.85 Stage of sleep N1 12.6 ± 12.8 14.1 ± 12.8 0.65 Stage of sleep N2 16.5 ± 9.3 16.8 ± 11.1 0.92 Stage of sleep N3 34.1 ± 10.9 30.5 ± 12 0.22 24.7 ± 12.2 23.7 ± 13.9 0.77 Sleep architecture NREM Phase (%)c REM Phase (%)d Stage of sleep R Data shown as: mean ± SD or % (number) a AHI -Apnea/Hypopnea Index classification: normal ( reported experiencing frequent unrefreshing sleep and uncontrollable sleepiness that interfered with life Limitation We had applied the self-reported assessment tools (questionnaires) for the evaluation of QOL and depression However, the chronotype was assessed by both objective methods (PSG) and morningness-eveningness questionnaire, to identify patients with OSA which gives better characteristic of the study population Further, it is very commonly observed that obese individuals underreport their dietary intake, which could also influence obtained results, especially considering that 24 h dietary recalls were applied However, in this case, the correlations that were found may support stronger relationships between nutrition and other analyzed factors showing the importance of dietary counselling in this specific group of patients Conclusions In conclusion, both chornotype and depression influence QOL in OSA patients where morning type is associated with better physical health and social relationships and increase in depression index deteriorate physical health, psychological and social relationship QOL domains QOL Stelmach-Mardas et al Health and Quality of Life Outcomes (2016) 14:111 Page of Table Correlation of Quality of Life Domains, depression, morningness-eveningness types and Apnea Hypopnea Index, selected cardio-metabolic biomarkers and nutrients (adjusted for age and sex; Pearson Partial Correlation Coefficients, n = 64) in in patients with Obstructive Sleep Apnea Analyzed variables Quality of life Depression inventory Morningnesseveningness (0.98) 0.11 (0.4) 0.15 (0.27) 0.19 (0.15) −0.06 (0.65) 0.13 (0.34) Physical health Psychological Social relationships Environment AHI (events/hours)a 0.11 (0.43) 0.13 (0.33) 0.07 (0.59) SBP (mmHg)b −0.02 (0.88) −0.03 (0.85) −0.12 (0.36) c DBP (mmHg) −0.25 (0.06) −0.36 (0.01) −0.29 (0.03) 0.01 (0.93) 0.17 (0.2) 0.05 (0.72) TC (mmol/dl)d 0.02 (0.86) 0.28 (0.04) 0.05 (0.73) 0.23 (0.08) −0.03 (0.8) −0.09 (0.52) HDL (mmol/dl)e −0.05 (0.7) 0.02 (0.88) −0.12 (0.38) 0.25 (0.06) −0.04 (0.77) 0.03 (0.84) LDL (mmol/dl)f 0.06 (0.68) 0.3 (0.02) −0.02 (0.89) 0.14 (0.31) −0.01 (0.94) −0.08 (0.57) TG (mmol/dl) 0.03 (0.82) 0.11 (0.4) 0.27 (0.04) 0.03 (0.8) 0.04 (0.75) −0.14 (0.28) Fasting glucose (mmol/dl) 0.03 (0.81) −0.08 (0.57) 0.03 (0.85) −0.1(0.45) 0.3 (0.02) 0.12 (0.37) g Energy (kcal) −0.09 (0.49) −0.04 (0.76) 0.23 (0.09) 0.08 (0.54) −0.06 (0.67) −0.13 (0.32) Carbohydrates (g) 0.01 (0.95) 0.02 (0.88) 0.2 (0.14) 0.18 (0.18) −0.04 (0.75) 0.05 (0.71) Protein (g) −0.2 (0.13) −0.12 (0.39) 0.27 (0.04) −0.01 (0.93) −0.08 (0.55) −0.14 (0.3) Fat (g) −0.11 (0.39) −0.07 (0.59) 0.17 (0.21) −0.03 (0.83) −0.05 (0.68) −0.28 (0.03) h −0.11 (0.39) −0.15 (0.27) 0.09 (0.52) −0.12 (0.38) −0.08 (0.56) −0.11 (0.43) MUFA (g)i −0.08 (0.53) −0.03 (0.85) 0.19 (0.14) 0.01 (0.96) −0.02 (0.86) −0.3 (0.02) SFA (g)j −0.12 (0.39) −0.07 (0.6) 0.13 (0.35) −0.01 (0.92) −0.06 (0.63) −0.27 (0.04) Vit B1 (mg) 0.11 (0.4) −0.01 (0.97) 0.13 (0.32) 0.19 (0.16) −0.12 (0.37) −0.02 (0.89) Vit B2 (mg) −0.18 (0.19) −0.03 (0.8) 0.19 (0.15) −0.06 (0.63) −0.09 (0.52) −0.08 (0.56) Vit B6 (mg) 0.06 (0.65) −0.06 (0.64) 0.27 (0.04) 0.15 (0.27) −0.13 (0.34) 0.05 (0.69) PUFA (g) Vit B12 (ug) −0.06 (0.67) 0.06 (0.63) 0.13 (0.33) −0.01 (0.95) −0.03 (0.82) −0.27 (0.04) Folate (ug) 0.05 (0.69) 0.05 (0.71) 0.2 (0.14) 0.08 (0.54) −0.2 (0.13) 0.18 (0.17) Vit D (ug) 0.05 (0.68) 0.09 (0.49) 0.12 (0.36) 0.06 (0.64) −0.09 (0.49) −0.25 (0.06) Data expressed as adjusted correlation coefficient (p-value) a AHI -Apnea/Hypopnea Index classification: normal (